|
08/16/2007 06:38 FAX BOVETT PETROLEUM [mol l/011
<br />i 0 4)
<br />UNDERGROUND STORAGE TANK SYSTEM
<br />OWNER STATEMENTS OF DESIGNATED UST OPERATOR AND
<br />UNDERSTANDING Or AND COMPLIANCE WITH UST REQUIREMENTS
<br />I,i)r use hI, (Lnirl<rc'a l4/tn:htrr,f �;ef:cicas or where apprcfved hrLocal ocal Jfff-ischction
<br />Aulhority� Cited. -Tide; 23. Div. 3, Ch. 16 Call%nrnia Code ol'Re;gwlations (CCR)
<br />FACILITY NAM FA('ll.rl'Y NIONH
<br />H & M MARKET (209) 838-3971
<br />.............._.-......................._......_....:......_,..-.w._.................,..._..._......__....._.._................... ......... .,,..... :.... .... ....................
<br />u_�.0
<br />FACII.1'1'Y Si'I.1- ADDRESS CITY
<br />2501 JACKSON AVE. ESCALON, CA. 95320
<br />It1:;r1tiVN 1�(.))( tit.11.iNtl'1'tIN(i'!'ItIS I�(.)Ith4 ((:'lre�ek (Jrre;l; �� t,:luall�d cli'1)t;;:ll�Ft,lt4d UI1c1'illur
<br />PRIMARY DIES C:NATED UST OPERATOR 11+OR'rHIS 1FA,C'IC,I'i Y
<br />t>�siUNAtl� 1(�trl.t�n'Id�tt NAME: KAREN ARNAIZ
<br />HUNINUSS NAME (1/ cp11irr'cvrr,f mn above).
<br />r)rSi(1NA1•Fr)()Pt,RA'rORPI-IONi:: (209)518-4836 ext,
<br />__...-._-......._._._..._-._.......•........................................................................_........... .-_................ _.......... ............
<br />_.__..._.........
<br />IN"ttil(Nn1'1(.)NALC:()I)1.:COUNCIL CIaRTIFIC'A11()NNO.: 5266643 -UC
<br />(-pdut� of l�:(: `.'rF'(Iticauc)n I,-Npir4001l 041C(S)
<br />A1..'1 ERNATF i DESIGNATED L)S; I' OPERATOR FOR RIAS FAC'II.,1'i'Y(gntinnrr!)..
<br />CIT'STrNAT)-r) QPrRA'r(.)R NAMI
<br />BUSTNF.SS NAME. 1't/tl!lr'rr.n1 frnnauhciwat:
<br />ht;SiGNATI77) 0PFRA'rONt III IONF- ( ) ext,
<br />INTE{RNATIONAI . C'(n)1 COUNCIL C ERTIFICA'1'ION NO.:
<br />_ _ _ .._ _ ._......._....._...............-............•............................... ..........
<br />...............................
<br />At,TFIZNA'f , 2 DESIGNATE.]) UST OPERATOR FOR TIiiS FACHATY
<br />_ �._..,...:�.....,....... �:......,...-....._....._.._ _ ..........._................,, .,.,.:......... .......
<br />,..
<br />DUSECiNA t I:L) ( IL KA14OR NAMFi:
<br />BUSINESS NAME (1/'di(%rrcrrf,frrnn above):
<br />....... ................ -.._._........._......-............
<br />DUS164NA11.:1) 011FRATOR PHONH: ( CXt.
<br />__..—.._................ ....... .......... ......... ...... ............... ............................. _..... ............... ... ....... ........................... ....
<br />INTERNATIONAi. CODE COUNCIL C"LIXIIFICIVI'ION NO.:
<br />__..__...._.._..._.... ......_............ .... .......................................... ......_:...:.:...,............. ..... ...... :........ ..:...,.......,................ .,......_........:.._,.......:,...•.....,.:..,.......... ................
<br />_
<br />AI: ERNA'I'F 3 DESIGNATED IJST OPERATOR FOR THIS FACTLITY tontionah
<br />®_.._.....,.,... ........ .... .:..,.,.".".:.-,.^.._._........
<br />RELATION TO 1_'ST FACILITY (biec-k orte)
<br />❑ Owner ❑ Operator ❑ E-mmovee
<br />❑ ticrvicc'i'c•c:hniciaa Ibirdd'arty
<br />........;... .................................................._.........._..........................._.................
<br />I:? 11IRA1'ION I)A'i'I':: 9/12/2007
<br />RITZ •AT IONTO I IST FACILITY (Choc A, C)ne}
<br />❑ Croner ❑ Operulor ❑ Pmploycr
<br />❑ Service!"edinician ❑ ')"bird -Party
<br />EXPIRATION DA I I -
<br />ItT:lAI'I0N TO l -1ST FACiLUY (Check One)
<br />❑ Owner u Operator ❑ Employee
<br />❑ Sorvicc `Ecchnician ❑ 'Third -Early
<br />__........... ... I ............... .... _--
<br />LXPIICA'NON DATE
<br />DI SIGN!1'rI'et: OPF'RATOR NAME: FEI.ATION'11) I!S'1' FAC;II.I'I'Y (C.hec:k c;)rre)
<br />—, . �.,..._..-...__...-.._.—.._........
<br />1iUSiNLSS NAMIi (.7/ dif/i re'nl�iun, ubu�r}: E] Omwr EJQperalur ❑ Fritpl(tvct:
<br />>tSSTGNA'1EL)LlT'LR,1F�>It P}IC)NF.: ( ) El Service Icchnici;an El"third-Party
<br />ext.
<br />INTF".RNATIUNAL t:ODE: C OUN(Al. CER NFICATU)N NO, ti\P1RA1'IpN DA I'I .
<br />I certify that, for Elle raciiity indicated at the top of this page, the individual(s) listed above Nvill serve ;as Designated) uST
<br />Operator(s). The individual(s) will conduct and document inunthly facility insticetions and tammatl facility employee training
<br />in accordance with California Code of Regulations, Title a3, lection 2715(c) through (t). Furthermore, I understand and am
<br />in compliance with the requirements (statutes, regulations, and local ordinances) applicable to underground storage tanks.
<br />TANK OWNF'17 "rlT1.l.: CUSTOM
<br />I'ANK OWNER SIGNATL-IRF"
<br />ES COORDINATOR 0WNH PMC}Tal:;; (209) 577-6000
<br />DA i.;.: August 15, 2007
<br />1. Report the namc•(s) of the l.)Csigm algid LJST Operators) as registered will) the. Internritfonal ('odc Council (ICC), ICC certificalion
<br />inforni ation is available on -lint: al: www.icesafc.t)r!,/e/certsearch.littit1. Search for "C,aliturnin 1,JST System Operators."
<br />2. Submit this completed form to the local agency that regulates this theility's LJSTs. Unidoes member agency jurisdictions and
<br />contact infurnlation are listed on-line at: www.unidoes.org/tnenibers/wlioi,egitlateswhat.htni. Contact infarination for other
<br />local agencies Within C;`,aliforitia is avai fable at. www.sivi-ch.ca.gov/cwphome/tist/cant.actr-/docs/loc.il_:age.ncy_list.xls.
<br />.J. 23 CCR }2715(1) requires that you notify the local agency of any changes to this inti}rm.ation within 30 days of the d a(c ol'changc.
<br />(IN -063- lit www.uaiclocs.urg 09MIOS
<br />
|